NASVH 2015 SUMMER CONFERENCE
Coming Together for America’s Heroes
presented by
Jane C. Belt, MS, RN, RAC-MT
Plante Moran, PLLC
614-222-9020
jane.belt@plantemoran.com
plantemoran.com
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NASVH’ Mission
The National Association State Veterans Homes' primary
mission is to ensure that each and every eligible U.S.
veteran receives the benefits, services, long term health
care and respect which they have earned by their service
and sacrifice. The organization also ensures that no
veteran is in need or distress and that the level of care
and services provided by state veterans homes meets or
exceeds the highest standards available.
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My Salute to You and
Your Mission
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Objectives
Delineate the Affordable Care Act as the nation’s
quality of care call to action
Identify the mindset of healthcare reform and how it
fits into quality outcomes
Review the multiple federal initiatives aimed to
improve quality of care
Describe practical solutions to impact the quality of
care for our veterans
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Having the Right Mindset
“It is not the strongest of the
species that survive, nor the
most intelligent, but the one
most responsive to change.”
Charles Darwin
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The Change Process Begins…
The current regulatory system was established under
Omnibus Budget Reconciliation Act (OBRA) 1987
1. Resident Rights, including patients to be called
residents
2. Residents are to receive care and services to
help them attain or maintain the highest level of
function – physical, mental, psychosocial
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OBRA Was Expected to:
Improve monitoring of poor performing facilities
More effective enforcement strategies
Encourage Quality Improvement
Increase knowledge and expectations of nursing
facility performance
Change the system to link the level of the
seriousness of the deficiency with the appropriate
penalty allowed by legislation
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Change Expected
Quality of care legislation with OBRA:
F520: Quality Assessment and Assurance defined as a
management process that is “ongoing, multi-level and
facility wide.”
Encompasses all managerial, administrative, clinical and
environmental services as well as the performance of
outside providers and suppliers of care and services
Facility to have a system to identify issues or concerns
and put corrections into place
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F520 Quality Assessment and
Assurance
A facility must maintain a quality assessment and
assurance (QAA) committee consisting of –
The director of nursing services;
A physician designated by the facility; and
At least 3 other members of the facility’s staff
The QAA committee:
Meets at least quarterly to identify issues with respect to
which QAA activities are necessary
Develops and implements appropriate plans of action to
correct identified quality deficiencies
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Something Was Missing
For over 20 years the regulations for QAA specified
the facility had a committee with certain members and
would met at least quarterly and develop plans of
action for identified deficiencies ----- but no
specifications as to the means and methods taken or
the action plan to implement the QAA regulations
March 23, 2010, Affordable Care Act passed –
nation’s quality of care call to action
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Patient Protection and
Affordable Care Act
Key provisions:
Expand access to insurance
Increase consumer protections
Emphasize prevention and wellness
Improve quality and system performance
Expand the health workforce
Curb rising health care costs
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Healthcare Reform =
The Triple Aim
Improve Access
Improve Quality
Control Costs
with Payment
Reform
Manage Population Health
Coordinate Care and Reduce Redundancy
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ACA Provision for Quality Changes
Section 6102 (c) of the ACA contained provisions
for establishing and implementing a QAPI program
for nursing homes so that outcomes are monitored
and analyzed correctly and improvement sustained
Program to include:
Establishing standards (regulations)
Providing technical assistance to homes on the
development of best practices
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Fitting into the BIG Picture
QAPI is required in other federally certified health
care programs – hospitals, transplant programs,
dialysis centers, ambulatory care, hospice
NH QAPI is to be consistent with other settings at a
high level, but also take into account issues unique to
the nursing home setting
continuous
QAPI – new realm of quality – systematic,
comprehensive, data-driven, proactive to
performance management and improvement
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The BIG Picture
The ultimate goal is to provide person-centered care –
to focus on the person living in the nursing home
Quality Assurance and Performance Improvement
(QAPI) does not refer to a program; rather, this is the
way we do our work
An effective QAPI plan creates a self-sustaining
approach to improving safety and quality while involving
all caregivers in practical and creative problem solving
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Continued Change Initiatives
Federal and
State Quality
Improvement
Initiatives
Partnership to
Improve
Dementia Care
Nursing
Home
Quality Care
Collaborative
Advancing
Excellence
Nursing Home
Campaign
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Quality
Assurance
Process
Improvement
PersonCentered Care
Practices
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Performance for Facilities
and Consumers
State Veteran Home commitment to customer service
quality and a desire to improve performance:
Consumer satisfaction
Meeting state survey standards
Participating in the Advancing Excellence in America’s
Nursing Homes Campaign
Resident review compliance
Standard and Compliance Surveys
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The Future of Healthcare
Providers will need to
increasingly assume financial
risk
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Traditional Payment (FFS)
Not Working
Viewed as insufficient at containing costs
Volume was rewarded
Limited shared risk
Where
are we
headed?
Value-based purchasing
Direct link between payment and outcome
Bundled payments
Greater focus on care coordination and prevention
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Organized System of
Delivering Care
Reduce and
Control
Costs
Improve
Outcomes
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Change in the News
April 20, 2015
CMS published in Federal Register proposed rule for SNF
PPS beginning October 1, 2015. Laying out future plans
to transition SNFs to quality-based payments
SNF payment rate increase of 1.4% (10/1/15)
SNF Quality Reporting Program (10/1/17) – 3 post-acute,
cross setting quality measures to be reported to receive
full payment under SNF PPS
SNF 30-day all-cause readmission measure for incentive
payments (10/1/18)
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Proposed: SNF Quality Reporting
Data Collection Source: MDS
Proposed Data Collection Period: 10/1/16 through 12/31/2016
Proposed Submission Deadline for FY18 Payment Determination: 05/15/2017
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Incentive pool created by Medicare rate reduction of 2%. Only 50-70% of
pool may be distributed back to SNFs.
High performance levels = receive incentive; low performing = penalty
CMS develops an all-cause, all-condition
readmission measure
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Public reporting of readmission
measure on Nursing Home Compare
• CMS develops all-condition, risk
adjusted potentially preventable
readmission measure
• SNFs start receiving results from CMS
SNF VBP begins and
incentives and
penalties applied
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Latest News.…
July 16, 2015: Federal Register CMS-3260-P (403 pages)
HHS proposes to improve care and safety for NH residents
Revisions mark first major rewrite of long-term conditions of
participation since 1991 (24 years!)
Quality and safety requirements for more than 15,000 nursing
homes and skilled nursing facilities to improve quality of life,
enhance person-centered care and services for residents in
nursing homes, improve resident safety, and bring these
regulatory requirements into closer alignment with current
professional standards
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Latest News.…
July 16, 2015: Federal Register CMS-3260-P
In addition to the rewrite of the long-term COP:
Long-awaited regulations QAPI regulations – facility staff
will be required to present a comprehensive, data-driven
QAPI plan to surveyors at the first annual survey after the
effective date of the regulation. Focus on indicators of
outcomes of care and quality of life
Facility staff must develop a compliance and ethics
program that prevents criminal, civil, and administrative
violations and promotes quality care
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Latest News.…
In addition to the rewrite of the long-term COP:
Facility assessment – development of a formal,
documented facility-wide assessment to determine what
resources a facility would need to care for its residents
competently during day-to-day operations and in
emergencies. Assess competencies of licensed nurses
to care for assessed resident needs
Resident rights – very detailed. Also report suspicion of
bodily harm within 2 hours and within 24 hours events that
did not cause bodily harm
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Latest News.…
In addition to the rewrite of the long-term COP:
Transitions of Care – replaces admission, transfer, and
discharge terms. Information required when resident goes
from one care setting to another. Compliance can be satisfied
with discharge summary containing required components.
Discharge to another provider (community with HHA, IRF, or
LTCH) – facility must assist in selecting provider. Data from
standardized post-acute assessment, QMs, other
Comprehensive resident-centered care plans – baseline
within 48 hours. IDT spelled out
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Latest News.…
In addition to the rewrite of the long-term COP:
Infection Control Officer – designate an Infection Prevention
and Control Officer (IPCO) employed at least part-time by the
facility; has specialized training in infection prevention and
control programming. Antibiotic stewardship program
Physician services – should be a physician, PA, NP, CNS
available (in person) to evaluate residents for non-emergency
transfer to a hospital; physician can delegate task of writing
dietary orders to a qualified dietitian and the task of writing
therapy orders to a qualified therapist
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Avalanche of Change Continues
MDS
QMs
Five-Star
Life Safety
Regulations
Medicare
Medicaid
Managed Care
Standards of
Care
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Have We Changed Our Practices?
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“I did then what I knew then,
when I knew better, I did better.”
~ Maya Angelou
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We Have Been Learning About
Quality – It Fits With the Mission
Level of care and services provided by state veterans
homes meets or exceeds the highest standards available
Quality Measures
State and Federal
surveys
Home-like
environment
Reducing
unnecessary
hospitalizations
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Resident choice
Resident satisfaction
Family satisfaction
Participates in
Advancing
Excellence
Five-Star rating
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We Are Finding More to Learn
Changing regulations
Changing reimbursement methodologies
Root cause analysis and critical thinking
Risks associated with psychoactive medications
Risks of over use of antibiotics
Potential negative outcomes from falls
Importance of reduction of pain and pain management
Person-centered care
Avoiding unnecessary hospitalizations
Proper skin care
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And much more…
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Impacting Quality of Care for Our
Veterans with Practical Solutions
Reducing unnecessary hospitalizations
INTERACT® Quality Improvement Program
We’ve learned
some
hospitalizations are
not necessary
Quality improvement tools – tracking, root cause
analysis
Communication tools – Stop and Watch, SBAR
Decision-support tools – care path protocols
Advanced care planning
Advancing Excellence Toolkit
STate Action on Avoidable Rehospitalizations (STARR)
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Five-Star
Quality Measures
Use 3 most recent
quarters of MDS
data
Long stay measures (8)
Short stay measures (3)
ADL help needs have increased  Pain – self-report
moderate to severe
High-risk pressure ulcers
 Pressure Ulcers – new or
Long-term catheter use
worsened
Physical restraints
 New antipsychotic
UTIs
medication use
Pain – self-report moderate to severe
pain
All 11 QMs based on national
percentile ranking, with the exception
Fall with major injury
of the ADL measure, which is based
Antipsychotic medication
on State ranking
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Surveyor Quality Measures
Long Stay
Depressive symptoms
Self-reported moderate/severe pain Urinary tract infections
Catheter inserted and left in bladder
High-risk residents w/ PUs
Low-risk residents who lose control
of bowel/bladder control
Physical restraints
Falls
Excessive weight loss
Falls with major injury
Need for ADL help has increased
Psychoactive med use in absence
of psychotic or related condition
Short stay
Antianxiety/hypnotic med use
New/worsened PU
Self-reported moderate/severe pain
Behavior symptoms affection others New antipsychotic med use
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Added for surveys
Used for 5-star
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We’ve Learned from Quality
Measures
Understanding process versus outcome
Looking at more than just the numbers
Root cause analysis
Critical thinking
Identifying risks with the risk
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Process Versus Outcome
PROCESS = course of action and procedures taken in
response to the resident’s assessed needs and
condition. Technical and interpersonal activities that
occur in the delivery of care and services
Include activities that go on within and between staff
and residents.
For example: residents with dementia exhibiting
behavioral symptoms
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Process Versus Outcome
OUTCOME = indication of the resident’s status in
terms of functional ability or clinical condition
An outcome represents the results of the applied
processes
For example, an incontinent resident with pressure
ulcers
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It’s Not The Numbers - It’s What
You Do With Them
Seeing the score is only the first step – QMs
indicate potential problems
Using the reports requires consideration of
how the QMs are scored, what residents are
excluded and which MDS items were used to
calculate each measurement
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Consider
 Retrospective data and methods indicate
potential problems that need further review
 Concurrent methods examine actual care and
clinical practices
 QMs assess performance of whole systems
and parts of systems for defined episodes of
care so QM efforts can be targeted
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Consider
 Analyze the underlying systems and
processes and determine where redesign
might reduce risk
 Identify risk areas and their potential
contributions to the event
 Determine the human and other factors most
directly associated with the event
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Consider
Determine potential improvement in processes or
systems that would tend to decrease likelihood of such
events in future, or decide after analysis, that no
improvement opportunities exist
Include participation by managers and the direct care
givers closely involved in the processes and systems
under review
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Root Causes - Identification
QM scores are often interrelated
The analytical and critical thinking involved in
identifying whether systems, knowledge or
performance problems exists and are the
causes of the negative outcome is one of the
most beneficial uses of the CMS QM tools
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Cause Identification
Multiple factors can contribute to a resident’s
susceptibility to negative outcomes. If a
facility addresses the risk factors within the
risk, they will be attempting to intervene in
areas contributing to the resident’s overall risk
for avoidable negative outcomes
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Risks within the Risk for
Incontinence
UTIs
Indwelling catheters
Falls
Falls with major injury
Pressure Ulcers
Dehydration
Depression/anxiety/isolation
Restraints
Pain and discomfort
Need for ADL help has increased
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What Were We Taught?
Restraints were safe and kept folks from falling
Bed rails are required on every resident bed
Indwelling catheters were needed if incontinence
could not be contained
Antibiotics were effective in fighting bacterial
infections
Every resident should be turned every 2 hours
Check and change every 2 hours
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What Do We Know about Urinary
Incontinence
Urinary incontinence (UI) is a common and potentially disabling
condition affecting up to 30% of those aged 65 years and older. In
nursing facilities up to 70% of residents are admitted with urinary
incontinence and an additional condition of some type of skin
breakdown
In nursing facilities incontinence contributes to quality of care
complications. For example residents can experience skin
irritation, develop pressure ulcers difficult to heal, experience falls
with fractures, and are predisposed to urinary tract infections.
The adverse psychological effects for incontinent residents are
pain, embarrassment and frustration.
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Impact on Our Veterans
Quality care and quality of life concern and QMs to be
measured against:
Incidence of pressure ulcers
Worsening pressure ulcers
Urinary tract infections
Falls
Is there an opportunity available for a solution to help
with all of these concerns?
Consider improved, quality moisture management
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What Have We Learned?
Research and technology has introduced new
information, tools, and solutions as we work to reduce
adverse events and manage moisture
Normal urine void = 8 to 12 fluid ounces
We can now measure the absorbency level of
incontinence products
We know what happens when pressure applied to the
product and it is already wet
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What Have We Learned
The design of an incontinence product can
improve clinical outcomes
Fragile skin can be protected against skin irritation and
rashes (moisture associated skin damage)
Reduction of incidents of UTIs and skin breakdown
Reduction in slips and falls related to incontinent
episodes
Caregivers protected from strain or injury due to
combative behavior or lifting
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What Have We Learned
Consider: how do you feel the next day if you
get a phone call during the night?
We have learned the importance and impact of sleep
Research has shown improved night time sleep
Improves veterans’ function
Improves mood and decrease behavioral episodes
Increases socialization
Promotes healing
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Confession of an Old Nurse
I will not use disposable paper briefs
I will leave residents “open to air” at
night
Residents need changed every 2
hours or the facility will smell
Residents need changed every 2
hours or they develop a UTI
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Forgive me… I Learned Better
There are products that offer improved clinical
outcomes and bottom line savings
I watched the demo, I talked to nurses who had used
the high absorbency products, I read the research, I
read the testimonials
Technology does improve the quality of life for
veterans --- and who deserves it more than our
veterans?
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Quality of Life -- What If
High absorbency product
Unsurpassed capacity protects against leaks and odors
Sleep through the night protection
Design eliminates feeling of wetness, cold, discomfort, and
associated night time falls
Less fatigue for caregivers especially with veterans with
dementia, impaired mobility, morbid obesity
Decreased skin breakdown
Decreased sleep disruption (night time sleep)
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The Cost Would be Millions!?!
What is the cost of incontinence?
Brief, pull ups
Barrier creams and lotions
Wipes, gloves, bed pads
Linen / clothing changes – detergents, utilities, waste,
trash
Skin breakdown, wound healing complications, UTIs
Employee morale and turnover – workers comp, lost time
Veteran, staff, visitor falls
Interrupted sleep – decreased healing
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What If – Change in Cost
Effectiveness?
Overall cost savings: fewer changes, fewer units
purchased, fewer units to dispose and less labor
required
Laundry savings: fewer bedding changes, fewer
clothing changes, less detergent and water usage,
longer linen life and less labor
Less impact on the environment – fewer units to
dispose
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Keys to Change –
What We Learned
“It is not the strongest of the
species that survive, nor the most
intelligent, but the one most
responsive to change.”
Charles Darwin
“I did then what I knew then,
when I knew better, I did better.”
Maya Angelou
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Are You Willing?
To change your ways to
change your outcomes
for your veterans?
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Questions??
THANKS for ATTENDING
Contact Information:
Jane Belt
Plante Moran Clinical Group
jane.belt@plantemoran.com
614-222-9020
THANKS to our SPONSOR
1-800-467-3224
Booth #16-17
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Resources
RAI MDS Manual http://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html
Advancing Excellence : www.nhqualitycampaign.org
Medicare Quality Improvement Community
www.medqic.org
Rotterman, Program Director for the Institute for PersonCentered Care. “Personal Alarms: Another Form of Restraint
and Oppression Among the Frail and Elderly? You Decide” July
30, 2013
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Resources
Fact sheet – Proposed fiscal year 2016 payment and
policy changes for Medicare Skilled Nursing Facilities
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Factsheets/2015-Fact-sheets-items/2015-04-15.html
Press Release 7/13/15: HHS proposes to improve care
and safety for nursing home residents.
http://www.hhs.gov/news/press/2015pres/07/20150713d.html
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Resources
MDS 3.0 Quality Measures - USER’S MANUAL (V8.0)
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/downloads/MDS30QM-Manual.pdf
QAPI web page: http://go.cms/gov/Nhqapi
QAPI at a Glance: http://tiny.cc/QAPI
Kulus, Judy RN, NHA, MAT, RAC-MT, C-NE.
“Proposed Changes to Nursing Home Rules: Biggest
Changes in 24 Years.” AANAC LTC Leader, 7/20/15
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